Tackling Nicotine Together

Associate
Professor Billie Bonevski is a National Health and Medical Research Council (NHMRC)
Career Development Fellow, Behavioural Scientist and University of Newcastle
researcher whose smoking cessation programs are being implemented by Cancer
Councils across the nation.

As
the leader of the NHMRC-funded Tackling Nicotine Together (TNT) program, which
aims to reorientate drug and alcohol treatment services, Associate Professor
Billie Bonevski aspires to ensure support is provided to help people quit
smoking.

"Hence
the extreme need to address drug and alcohol service clients' smoking."

The
TNT study is the first in Australia to increase tobacco dependence treatment to
patients. A collaborative endeavour
between the University of Newcastle, the Cancer Council NSW, the National Drug
and Alcohol Research Centre (UNSW), and the Network of Alcohol and Other Drug
Agencies, it is a staff-centric project with more than 30 centres nationally.

The
project focuses on building the capacity of treatment centres, to insure that these
centres can provide their clients with the support needed to quit smoking. Centre staff are trained in treating tobacco
dependency, have access to free nicotine replacement stock to give to clients,
and are linked to Quitline for more involved treatment.

HEALTH PRIORITY

For
the past five years, Billie's work has focused on priority groups, such as those
who may be socio-economically disadvantaged, or people with comorbidities like
cancer or chronic illness. Health initiatives, up until now, have largely
ignored these groups, choosing instead to target the broader Australian public
with health education.

"Generally
speaking, such measures have been effective, but there are pockets of society
who have missed the message or experience a lack of services to help them deal
with their unique challenges," Billie states.

She
feels that targeting groups has been a significant advance in the field,
particularly as one of her recent studies shows that one in four Australians
will experience some sort of comorbidity or disadvantage at any given time.

IN THE BEGINNING

With
a Bachelor of Arts and First Class Honours in Psychology (and the departmental
prize for best applied thesis) from the University of Newcastle, Billie began
work as a research assistant to Rob Sanson-Fisher, then Head of Behavioural
Science in the Faculty of Medicine. Flourishing in the role she began her PhD
in Behavioural Science, developing, as part of her thesis, a desktop computer
program for GPs. This program would
remind doctors to carry out preventative activities in each patient
consultation, such as suggesting a patient quit smoking, or reminding women of
the need of a pap smear.

"The
program was found to increase rates of preventative care," Billie remarks.

"Which
I still find really nice!"

Despite
undertaking a valuable year at the University of Oxford in the UK in 1997, for
a World Health Organisation General Practice research fellowship, Billie was
drawn back home. Bolstered by the
knowledge that the University of Newcastle is a national leader in public
health research, prompted Billie not only to return, but to stay. As she says now "Why would you move?"

HEALTH BEHAVIOUR

Billie's
background in psychology has proved to be highly applicable to her present
studies. Her primary focus is on
improving people's health behaviour by developing programs so they can optimise
their own health through modified behaviours.

"Psychology
provides the tools and the strategies for behaviour change," she confirms.

"Whether
it be goal-setting, cognitive behaviour therapy or other tactics to arm people
with the means to change."

Encouraging
smokers to smoke less, drinkers to drink less and getting people to wear sunscreen
are just some examples.

"It's
about trying to get people on the path to health again through preventative
actions and health-behaviour change," Billie says.

While
Billie's work is particular to the Australian psychosocial situation, it has
significance for the world population. Globally, health equity is a pertinent
issue recognised by researchers as an area in dire need of addressing.

"Health
improvement affects everybody," Billie points out.

"My
research is one piece of the jigsaw puzzle to ending health inequities."

"Nonetheless,
as the local health community is increasingly recognising, it's a key one."

USING THE DATA

Six
months after the TNT project, data will be collected to determine the
effectiveness of system change intervention for smoking in drug and alcohol
centres across Australia. Questions will
be asked as to whether clients felt they received more treatment from centre staff
to tackle tobacco dependency; if they felt it helped them quit, and the level
of smoking cessation.

The
potential of this valuable data is that the government can use it to inform
public health policy, hence preventing the burden of illness caused by tobacco.

Billie's
previous research with the Cancer Council New South Wales 'Tackling Tobacco Program'
has attracted the interest of Cancer Councils in Victoria, Queensland and
Western Australia. To translate the NSW-based research widely, a Tackling
Tobacco National Implementation Group has been formed to focus on vulnerable
people's use of the substance. This
bodes well for the TNT project.

Billie,
a University of Newcastle Gladys M Brawn Career Development Fellow, is
frequently invited as a keynote speaker in national smoking cessation and skin
cancer forums, and often honoured in being able to set the agenda. She's able to present data based on the
research being undertaken at the University of Newcastle, on why focusing on
tobacco research in long-neglected priority groups is important.

"If
you're refocusing the national agenda on the sort of research that should
actually be occurring, then you're training up the future that's going to
sustain what you're doing now," Billie says.

Her
Newcastle team's research work is leading the nation, and is evidently able to
command the attention of the tobacco control community. This, together with her role as a keynote
speaker and her success in attracting valuable funding from the NHMRC, is a
great incentive and inspiration for Billie's five current PhD students, who are
able to work on her important projects.

Career Summary

Biography

Billie Bonevski, BA(Hons), PhD is an Associate Professor of health behaviour science and National Health and Medical Research Council (NHMRC) Career Development Fellow and Faculty of Health and Medicine Gladys M Brawn Career Development Fellow at the School of Medicine and Public Health, University of Newcastle. Her research focusses on developing and evaluating methods to help people change their health behaviours and improve their well-being as well as developing strategies to help organisations and services better meet their clients’ health needs. In particular, she is currently leading a number of smoking cessation trials which target vulnerable groups such as those with mental illness and physical co-morbidities, the unemployed and homeless and people with drug and alcohol addiction. She is currently chief investigator on five NHMRC smoking cessation trials including: examining a client-centred, case worker delivered smoking cessation intervention in social and community service organisations; a trial of an organisational change intervention for smoking cessation in drug and alcohol treatment centres and a trial of a financial counselling intervention to reduce smoking in socioeconomically disadvantaged groups.

CollaborationsBillie Bonevski has a broad network of research collaborations that include local, national and international research leaders, as well as community based partners and industry collaborators.

Qualifications

PhD (Medicine), University of Newcastle

Bachelor of Arts, University of Newcastle

Bachelor of Arts (Honours), University of Newcastle

Keywords

Public Health

cancer control

health promotion

tobacco control

Fields of Research

Code

Description

Percentage

111299

Oncology and Carcinogenesis not elsewhere classified

10

170199

Psychology not elsewhere classified

20

111799

Public Health and Health Services not elsewhere classified

70

Professional Experience

UON Appointment

Title

Organisation / Department

NHMRC Career Development Fellow

University of NewcastleSchool of Medicine and Public HealthAustralia

Academic appointment

Dates

Title

Organisation / Department

1/06/2011 - 1/06/2014

Fellow

University of NewcastleSchool of Medicine and Public HealthAustralia

1/01/2010 -

Behavioural Scientist

National Skin Cancer Committee, Cancer Council AustraliaAustralia

1/01/2007 - 1/12/2007

Senior Research Academic

University of NewcastleClinical PharmacologyAustralia

Membership

Dates

Title

Organisation / Department

1/01/2012 -

Membership

Hunter Cancer Research AllianceAustralia

Awards

Research Award

Year

Award

2011

Publication AwardPriority Research Centre for Health Behaviour (CHB)

1992

WH Ward Prize for Best Applied ThesisUniversity of Newcastle - Faculty of Science & IT

Invitations

Keynote Speaker

Year

Title / Rationale

2014

Oceania Tobacco Control ConferenceOrganisation: Perth
Description:
Smoking and Social Disadvantage

Television advertisements, packaging regulations and health warning labels (HWLs) are designed to communicate anti-smoking messages to large number of smokers. However, only a few... [more]

Television advertisements, packaging regulations and health warning labels (HWLs) are designed to communicate anti-smoking messages to large number of smokers. However, only a few studies have examined how high smoking prevalence groups respond to these warnings. This study explored how socioeconomically disadvantaged smokers engage with health risk and cessation benefit messages. Six focus groups were conducted over September 2012-April 2013 with adult clients of welfare organizations in regional New South Wales, Australia who were current smokers (n = 51). Participants discussed HWLs, plain packaging and anti-smoking television advertisements. Discussions were audio-taped, transcribed verbatim and analysed using thematic analysis. Highly emotive warnings delivering messages of negative health effects were most likely to capture the attention of the study participants; however, these warning messages did not prompt quit attempts and participants were sceptical about the effectiveness of cessation programmes such as telephone quitlines. Active avoidance of health warning messages was common, and many expressed false and self-exempting beliefs towards the harms of tobacco. Careful consideration of message content and medium is required to communicate the anti-smoking message to disadvantaged smokers who consider themselves desensitized to warnings. Health communication strategies should continue to address false beliefs about smoking and educate on cessation services that are currently underutilized.

Background: Online continuing medical education (CME) offers a number of advantages for physicians including flexibility with regards to location and timing of use. In order to ef... [more]

Background: Online continuing medical education (CME) offers a number of advantages for physicians including flexibility with regards to location and timing of use. In order to effect physician practices and improve patient outcomes, it is important that the development of online CME is theory and evidence-based. Objectives: This paper aims to describe the development of an online CME program for practising general practitioners (GPs) on vitamin D and sun health called "The ABC's of Vitamin D for GPs" using elements of design principles for physician-education web sites as a framework. The paper will also report the program's usability and acceptability pilot test results. Methods: The ABC's of Vitamin D program was developed following nine principles: needs assessment; evidence-based content development; multimodal program and modularisation; clinical cases; tailoring and interactivity; audit and feedback; credibility of the web site host; patient education materials; ease of use and navigation. Among the 20 GPs invited, acceptability and useability was tested with 12 GPs (60%) who agreed to participate and were interviewed following use of the program. The study was conducted between 2011 and 2013. Results: An online CME program consisting of eight modules was constructed. Of the 12 participating GPs, most (. n=. 11) reported that the program was clear and easy to understand, logical, easy to navigate, and took a reasonable amount of time (estimated between 1 and 3. h) to complete. Eleven of 12 participants said they would use the program as an accredited CME activity and all participants indicated that the program was 'very or somewhat' likely to lead to changes in the advice patients are given. Conclusion: This study found that a theory and evidence based approach for the development of an online CME program for GPs was acceptable to users. Further research is needed to examine whether the online CME program is effective at changing GP practices and improving patient outcomes.

Background: Technical and Further Education (TAFE) colleges are the primary provider of vocational education in Australia. Most TAFE students are young adults, a period when healt... [more]

Background: Technical and Further Education (TAFE) colleges are the primary provider of vocational education in Australia. Most TAFE students are young adults, a period when health risk behaviours become established. Furthermore, high rates of smoking, risky alcohol consumption, inadequate fruit and vegetable intake and insufficient physical activity have been reported in TAFE students. There have been no intervention studies targeting multiple health risk behaviours simultaneously in this population. The proposed trial will examine the effectiveness of providing TAFE students with electronic feedback regarding health risk behaviours and referral to a suite of existing online and telephone services addressing smoking, risky alcohol consumption, fruit and vegetable intake, and physical activity levels. Methods/Design: A two arm, parallel, cluster randomised trial will be conducted within TAFE campuses in New South Wales (NSW), Australia. TAFE classes will be randomly allocated to an intervention or control condition (50 classes per condition). To be eligible, students must be: enrolled in a course that runs for more than 6 months; aged 16 years or older; and not meet Australian health guideline recommendations for at least one of the following: smoking, alcohol consumption, fruit and/or vegetable intake, or physical activity. Students attending intervention classes, will undertake via a computer tablet a risk assessment for health risk behaviours, and for behaviours not meeting Australian guidelines be provided with electronic feedback about these behaviours and referral to evidence-based online programs and telephone services. Students in control classes will not receive any intervention. Primary outcome measures that will be assessed via online surveys at baseline and 6 months post-recruitment are: 1) daily tobacco smoking; 2) standard drinks of alcohol consumed per week; 3) serves of fruit consumed daily; 4) serves of vegetables consumed daily; and 5) metabolic equivalent minutes of physical activity per week. Discussion: Proactive enrolment to existing online and telephone services has the potential to address modifiable determinants of disease. This trial will be the first to examine a potentially scalable intervention targeting multiple health risk behaviours among students in the vocational training setting.

Background: Online continuing medical education (CME) offers a number of advantages for physicians including flexibility with regards to location and timing of use. In order to ef... [more]

Background: Online continuing medical education (CME) offers a number of advantages for physicians including flexibility with regards to location and timing of use. In order to effect physician practices and improve patient outcomes, it is important that the development of online CME is theory and evidence-based. Objectives: This paper aims to describe the development of an online CME program for practising general practitioners (GPs) on vitamin D and sun health called "The ABC's of Vitamin D for GPs" using elements of design principles for physician-education web sites as a framework. The paper will also report the program's usability and acceptability pilot test results. Methods: The ABC's of Vitamin D program was developed following nine principles: needs assessment; evidence-based content development; multimodal program and modularisation; clinical cases; tailoring and interactivity; audit and feedback; credibility of the web site host; patient education materials; ease of use and navigation. Among the 20 GPs invited, acceptability and useability was tested with 12 GPs (60%) who agreed to participate and were interviewed following use of the program. The study was conducted between 2011 and 2013. Results: An online CME program consisting of eight modules was constructed. Of the 12 participating GPs, most (. n=. 11) reported that the program was clear and easy to understand, logical, easy to navigate, and took a reasonable amount of time (estimated between 1 and 3. h) to complete. Eleven of 12 participants said they would use the program as an accredited CME activity and all participants indicated that the program was 'very or somewhat' likely to lead to changes in the advice patients are given. Conclusion: This study found that a theory and evidence based approach for the development of an online CME program for GPs was acceptable to users. Further research is needed to examine whether the online CME program is effective at changing GP practices and improving patient outcomes.

Objective: Understanding smokers' quit experiences and their preferences for a future quit attempt may aid in the development of effective cessation treatments. The aims of this s... [more]

Objective: Understanding smokers' quit experiences and their preferences for a future quit attempt may aid in the development of effective cessation treatments. The aims of this study were to measure tobacco use behaviour; previous quit attempts and outcomes; methods used to assist quitting; difficulties experienced during previous attempts; the motives and preferred methods to assist quitting in a future attempt; identify the factors associated with preferences for smoking cessation. Design: Face-to-face interview using a structured questionnaire. Setting: Inpatient wards of three Australian public hospitals. Participants: Hospitalised smokers enrolled in a smoking cessation trial. Results: Of 600 enrolled patients (42.8% participation rate), 64.3% (n=386) had attempted quitting in the previous 12 months. On a scale of 1 (low) to 10 (high), current motivation to quit smoking was high (median 9; IQR 6.5-10), but confidence was modest (median 5; IQR 3-8). Among 386 participants who reported past quit attempts, 69.9% (n=270) had used at least one cessation aid to assist quitting. Nicotine replacement therapy (NRT) was most commonly stated (222, 57.5%), although the majority had used NRT for <4 weeks. Hypnotherapy was the most common (68, 17.6%) non-pharmacological treatment. Over 80% (n=311) experienced withdrawal symptoms; craving and irritability were commonly reported. Most participants (351, 58.5%) believed medications, especially NRT (322, 53.7%), would assist them to quit in the future. History of previous smoking cessation medication use was the only independent predictor of interest in using medications for a future quit attempt. Conclusions: The majority of smokers had attempted quitting in the previous 12 months; NRT was a popular cessation treatment, although it was not used as recommended by most. This suggests a need for assistance in the selection and optimal use of cessation aids for hospitalised smokers. Trial registration number: Australian and New Zealand Clinical Trials Registry: ACTRN12612000368831.

Introduction and Aims.: Understanding how tobacco, alcohol and mental health are related is important for developing population-level policies and individual-level treatments that... [more]

Introduction and Aims.: Understanding how tobacco, alcohol and mental health are related is important for developing population-level policies and individual-level treatments that target comorbidities. The current study aimed to examine sociodemographic characteristics and mental health comorbidities associated with the odds of using tobacco and harmful levels of alcohol concurrently. Design and Methods.: Data were drawn from the 45 and Up Study, a large cohort study with 267153 adults aged 45 years and over in New South Wales, Australia. Participants completed a survey assessing alcohol, smoking, psychological distress, treatment for depression and anxiety, and a range of socioeconomic status indicators. Univariate analyses and three multiple-logistic regression models were used to determine associations with (i) tobacco but not alcohol use; (ii) alcohol but not tobacco use; and (iii) concurrent tobacco and risky levels of alcohol use. Results.: Being female, younger, lower individual and area-level socioeconomic status (SES) and depression and psychological distress were associated with tobacco use alone. Factors associated with alcohol use alone were older age, male gender, higher SES, and lower psychological distress and no recent depression treatment. Factors associated with concurrent risky alcohol consumption and tobacco use included being 45-64, being male, less education, earning

Background: Despite years of public education, sun-related behaviours are difficult to change and a recent survey showed low levels of sun protection. In this study we evaluated t... [more]

Background: Despite years of public education, sun-related behaviours are difficult to change and a recent survey showed low levels of sun protection. In this study we evaluated the feasibility and acceptability of an opportunistic skin cancer prevention intervention in general practice. Methods. We used a controlled pre-and-post intervention design. Participants (n = 100) were recruited sequentially from patients attending two general practices in Sydney, Australia, from November to December 2010. Participants in the intervention practice (n = 50) received general practitioner delivered sun protection advice after completing a skin cancer risk assessment tool, and a sun protection pamphlet, in addition to routine care, at a single attendance. The skin cancer risk assessment tool provided three levels of risk. The general practitioner (GP) reinforced the level of risk and discussed sun protection. Participants in the control practice (n = 50) received routine care. We measured feasibility by patients' and GPs' participation in the intervention and time taken, and acceptability by intervention participants and GPs ratings of the intervention. We measured reported sun-related knowledge, attitudes and behaviour between the two groups at 1 and 13 months. Results: The intervention was found to be feasible within existing primary care team arrangements. Participation at baseline was 81% (108/134), and repeated participation was 88% (88/100) at 1 month and 70% (70/100) at 13 months. Participants and practitioners found the intervention acceptable. At 1 month, sun-related knowledge had increased in both patient groups, with a greater increase in the intervention group (adjusted mean difference 0.48, p = 0.034). There were no differences between groups in sun-related knowledge, attitudes and behaviour at 13 months. Conclusions: A brief opportunistic skin cancer prevention intervention in general practice is feasible and acceptable. Further research in this setting with a more intensive intervention would be justified.

Objectives: To identify barriers that are common and unique to six selected vulnerable groups: low socioeconomic status; Indigenous; mental illness and substance abuse; homeless; ... [more]

Objectives: To identify barriers that are common and unique to six selected vulnerable groups: low socioeconomic status; Indigenous; mental illness and substance abuse; homeless; prisoners; and at-risk youth. Design: A systematic review was carried out to identify the perceived barriers to smoking cessation within six vulnerable groups. Data sources: MEDLINE, EMBASE, CINAHL and PsycInfo were searched using keywords and MeSH terms from each database's inception published prior to March 2014. Study selection: Studies that provided either qualitative or quantitative (ie, longitudinal, crosssectional or cohort surveys) descriptions of selfreported perceived barriers to quitting smoking in one of the six aforementioned vulnerable groups were included. Data extraction: Two authors independently assessed studies for inclusion and extracted data. Results: 65 eligible papers were identified: 24 with low socioeconomic groups, 16 with Indigenous groups, 18 involving people with a mental illness, 3 with homeless groups, 2 involving prisoners and 1 involving at-risk youth. One study identified was carried out with participants who were homeless and addicted to alcohol and/or other drugs. Barriers common to all vulnerable groups included: smoking for stress management, lack of support from health and other service providers, and the high prevalence and acceptability of smoking in vulnerable communities. Unique barriers were identified for people with a mental illness (eg, maintenance of mental health), Indigenous groups (eg, cultural and historical norms), prisoners (eg, living conditions), people who are homeless (eg, competing priorities) and at-risk youth (eg, high accessibility of tobacco). Conclusions: Vulnerable groups experience common barriers to smoking cessation, in addition to barriers that are unique to specific vulnerable groups. Individual-level, community-level and social networklevel interventions are priority areas for future smoking cessation interventions within vulnerable groups

Paul CL, Turon H, Bonevski B, Bryant J, McElduff P, 'A cross-sectional survey of experts' opinions about the relative effectiveness of tobacco control strategies for the general population versus disadvantaged groups: What do we choose in the absence of evidence?', BMC Public Health, 13 (2013) [C1]

Lynagh MC, Sanson-Fisher RW, Bonevski B, 'What's Good for the Goose is Good for the Gander. Guiding Principles for the Use of Financial Incentives in Health Behaviour Change', INTERNATIONAL JOURNAL OF BEHAVIORAL MEDICINE, 20 114-120 (2013) [C1]

Bryant JL, Bonevski B, Paul CL, 'A survey of smoking prevalence and interest in quitting among social and community service organisation clients in Australia: a unique opportunity for reaching the disadvantaged', BMC Public Health, 11 827 (2011) [C1]

BACKGROUND: The aim of this study was to determine the prevalence and predictors of the perceived unmet needs of cancer patients undergoing treatment for their disease at public t... [more]

BACKGROUND: The aim of this study was to determine the prevalence and predictors of the perceived unmet needs of cancer patients undergoing treatment for their disease at public treatment centers. METHODS: A total of 1,492 consecutive patients attending the surgical, radiation, or medical oncology departments of 9 major public cancer treatment centers in New South Wales, Australia, were asked to participate. Of the 1,370 eligible patients, 1,354 (99%) consented to participate and 888 (65%) returned completed surveys. Eligible consenting patients were given a Supportive Care Needs Survey to complete at home and return by mail within 7 days. RESULTS: Patients' perceived needs were assessed across the following five areas: psychologic, health system and information, physical and daily living, patient care and support, and sexuality. Patients' perceived needs were highest in the psychologic, health system and information, and physical and daily living domains. Logistic regression modeling revealed subgroups of patients with different types of needs. The significant predictors of reporting some unmet need for help varied according to the domain examined. CONCLUSIONS: This statewide study shows that cancer patients experience high levels of unmet needs across the range of domains examined. The study provides information that may be valuable in identifying areas where interventions could be tested and evaluated in an attempt to address the unmet needs of people living with cancer. Copyright 2000 American Cancer Society.

Paul CL, Bonevski B, Bryant JL, Sanson-Fisher RW, 'Approaches to tobacco control and population effects: how good is the evidence that standard approaches are equitable', 12th Annual Meeting of the SRNT Europe Programme, Bath, UK (2010) [E3]

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